Nursing Elites

1. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

2. A client with lupus experience Raynaud's phenomenon. What should the nurse include when providing client education about this?

• A. In order to avoid flare-ups of Raynaud's, ensure you wear gloves in winter.'
• B. In order to avoid flare-ups of Raynaud's, ensure you brush your teeth for 2 minutes.'
• C. In order to avoid flare-ups of Raynaud's, ensure to keep cool.'
• D. In order to avoid flare-ups of Raynaud's, ensure you wear sunscreen.'

Correct answer: A

Rationale:

3. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

• A. Two-point gait
• B. Three-point gait
• C. Four-point gait
• D. Unaffected gait

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

4. Which client is at highest risk of compromised immunity?

• A. A client who just had surgery
• B. A client who just delivered a baby
• C. A client with extreme anxiety
• D. A client who is awaiting surgery

Correct answer: A

Rationale:

5. A client has cellulitis on his left arm. What statement by the client indicates understanding of symptom management?

• A. "I can use tight bandages on my arm."?
• B. "I should not apply heat to my arm."?
• C. "I can use a warm, moist towel on my arm."?
• D. "I should use a cold, dry source on my arm."?

Correct answer: C

Rationale:

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